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APPL I CATI ON'.ftR PERM I T - SAN _JO�WgfflTY PUBft SERVICES WISRONMENTAL HEALTHON nr'rT UIN GOt 445 N *N JOAQIIIN, PHONE 8-3420 � ? ►, ` SAls 10 ENVY' �j X 2009.,,*STOCKTON,7 1 D1V1 8N8 4 nom.;' D�_-CN CFS PERMIT EXPIRES 1 YEAR FROM DATE ISSUE (Complete in Triplicate) t� r Application is hereby made.to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San a Joaquin County Public Health Services. Job Address -3�'�oor Jijfssc�/ ff'c�, i.C/ ,:� Iyi City />/3 Lot Size/Acreage Owner's Name7 Y." X L-l-7�'Sc?t,/ Address SLA Phone A&Contractor -570ey Address 611-7 F License No.yKV E 9/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLL.Q�Aahto,. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 n Industrial ❑ Open Bottom ❑ Manteca { Dia. of Well Excavation Dia. of Well Casing 0 G 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Q I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Vol Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONAL DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth i17/ Size X / A Number f SUMPS of Distance to nearest: Well A/0 Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant myst call for all required inspections. Complete drawing on reverse side. Signed X Id' a Title: Date: OR DEPARTMENT USE ONLY I Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspectionby L.¢!°s1t�_ Date f� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8y DATE PERMIT'N0. . EMI o-z4(REV., s, $/V- 11`r� �l 2_72-3 �" ( C-701 - 24 EN 14.16